Reporting Multiple Organ Impairments
FormsNet3SM application: Complete questions 84 – 94 for each co-exiting disease or organ impairment by adding an additional instance in the FormsNet3SM application.
Paper form submission: Complete questions 84 – 94 for each co-exiting disease or organ impairment.

Question 84: Specify co-existing diseases or organ impairments any time prior to the start of the preparative regimen

Indicate if the recipient had any co-existing disease or organ impairments any time prior to the start of the preparative regimen / infusion. Report all co-existing disease or organ impairments.

  • Amenorrhea: Absence of menstruation
  • Cardiomyopathy: A disease of the heart muscle that makes it more difficult for the heart to pump blood to the rest of the body
  • Cholelithiasis: Presence of one or more gallstones in the gallbladder
  • Growth hormone deficiency / short stature: A condition in which the body does not produce enough growth hormone / a reduced overall rate of growth.
  • Hypersplenism: Overactive spleen. Diagnosis is typically based on a physician’s exam (checking for splenomegaly), a CBC to assess the concentration of red and white blood cells, and / or an ultrasound, measuring the size of the spleen.
  • Hypothyroidism requiring replacement therapy: Decreased activity of the thyroid gland. Diagnosis of hypothyroidism includes high levels of thyroid-stimulating hormone (TSH). Symptoms of hypothyroidism include fatigue, depression, weakness, weight gain, musculoskeletal pain, decreased taste, hoarseness, and / or puffy face.
  • Osteopathies (porosis, penia): Includes osteoporosis or osteopenia. Osteopathies should be reported if osteopenia or osteoporosis is documented within the medical record by the physician or based on the Z or T-score. Osteopenia is defined as a Z or T-score between -1.0 and -2.0 by a DEXA or quantitative CT scan. Osteoporosis is defined as a Z or T-score less than -2.0 by a DEXA or quantitative CT scan.
  • Pulmonary hypertension: Refers to elevated pulmonary arterial pressure and is diagnosed either by an echocardiogram or right heart catherization
  • Retinal changes: Changes include but are not limited to macular degeneration, floaters, diabetic eye disease, retinal detachment, and retinitis pigmentosa.
  • Thrombosis: Blood clot within a vein or artery.

If there were no co-existing diseases or organ impairments prior to the start of the preparative regimen / infusion, select None and continue question 95.

Question 85: Date of diagnosis

Report the diagnosis date of the co-existing disease or organ impairment. If the organ impairment occurred multiple time times prior to the start of the preparative regimen, report the co-existing disease or organ impairment once and the diagnosis date of the most recent occurrence. See the example below for additional information.

If the exact date is not known report an estimated date and check the Date estimated box. Refer to General Instructions, General Guidelines for Completing Forms for information about reporting estimated dates.

Example A: A recipient developed a blood clot (thrombosis) on 1/15/2015 which resolved; however, the recipient developed another blood clot 8/20/2019. The recipient’s transplant was on 12/1/2019. The diagnosis date of the thrombosis should be reported as 8/20/2019 as this is the date of the most recent episode.

Question 86: Method used to assess osteopathies (report the most recent Z-score or T-score available; Z-scores are used in patients younger than or equal to 20 and T-scores in patients older than 20) (check all that apply)

Specify the method used to assess osteopathies at any time prior to the start of the preparative regimen / infusion. Select all that apply.

If the osteopathy was not assessed at any time prior to the start of the preparative regimen / infusion or it is not known if assessed, select Unknown and continue with question 95.

Questions 87 – 88: DEXA scan vertebral

Indicate if the vertebral Z-score by DEXA is known. If Known, report the Z or T-score. Select Negative value if the Z or T-score is a negative (i.e., Z-score is -1.0).

If multiple DEXA scans were performed prior to the start of the preparative regimen / infusion, report the most recent vertebral Z or T-score.

Questions 89 – 90: DEXA scan hip

Indicate if the hip Z-score by DEXA is known. If Known, report the Z or T-score. Select Negative value if the Z or T-score is a negative (i.e., Z-score is -1.0).

If multiple DEXA scans were performed prior to the start of the preparative regimen / infusion, report the most recent hip Z or T-score.

Questions 91 – 92: Quantitative CT vertebral

Indicate if the vertebral Z-score by quantitative CT is known. If Known, report the Z or T-score. Select Negative value if the Z or T-score is a negative (i.e., Z-score is -1.0).

If multiple quantitative CT scans were performed prior to the start of the preparative regimen / infusion, report the most recent vertebral Z or T-score.

Questions 93 – 94: Quantitative CT hip

Indicate if the hip Z-score by quantitative CT is known. If Known, report the Z or T-score. Select Negative value if the Z or T-score is a negative (i.e., Z-score is -1.0).

If multiple quantitative CT scans were performed prior to the start of the preparative regimen / infusion, report the most recent hip Z or T-score.

Section Updates:

Question Number Date of Change Add/Remove/Modify Description Reasoning (If applicable)
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Last modified: Apr 24, 2022

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